A5b Individual Assent-Consent Form_English Version

Appendix A-5b

Individual Assent/Consent Form

National Food Study Pilot

Agency: Economic Research Service

Contractor: Westat, Inc.

Individual Assent/Consent Form

(This page will appear the first time a participant accesses the Food Log on the website)

OMB Control Number: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Your household was selected at random and has agreed to join this study. If you agree to participate, we ask you to keep track of the foods that you get for 7 days and to save receipts from the food that you buy. You also agree that we can use, for study purposes, the information about you that was provided by the primary adult living with you (who already gave his or her permission for you to participate). It will take up to 25 minutes of your time each day and you will receive $3 for every day that you report the food that you get. You will also receive $5 for reporting your income if you are at least 16 years old. The primary adult will be able to view the information you provide. Participation is voluntary. There are few risks to being in this study. We are required by law to use your information for this study only and to keep it protected. The law prevents us from giving anyone any information that may identify you or your family. There are no direct benefits from being in this study but we hope that you will participate.

If you decide not to take part it will not affect any benefits or services received by anyone in your household. Your information will be kept private and will not be released in a form that might identify you.

□ Please check this box if you agree to take part in this study.

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